<!--
 * Copyright TLR Team, Inc. All Rights Reserved.
-->
<div class="tlr-assessment-container">
    <form class="form-horizontal">
        <div class="form-group">
            <div class="col-sm-12 tlr-split-line">
                <label class="col-sm-3 control-label">1.个人基本信息</label>
            </div>
            <div class="col-sm-12 tlr-split-line">
                <label class="col-sm-3 control-label">客户信息:</label>
            </div>            
        </div>
        <div class="form-group">
            <label class="col-sm-2 control-label">姓名</label>
            <div class="col-sm-9">
                <input type="text" class="form-control" ng-model="assessment.personalInformation.name">
            </div>
        </div>
        <div class="form-group">
            <label class="col-sm-2 control-label">称呼</label>
            <div class="col-sm-9">
                <input type="text" class="form-control" ng-model="assessment.personalInformation.title">
            </div>
        </div>
        <div class="form-group">
            <label class="col-sm-2 control-label">电话</label>
            <div class="col-sm-9">
                <input type="text" class="form-control" ng-model="assessment.personalInformation.tel">
            </div>
        </div>
        <div class="form-group">
            <label class="col-sm-2 control-label">地址</label>
            <div class="col-sm-9">
                <input type="text" class="form-control" ng-model="assessment.personalInformation.address">
            </div>
        </div>
        <div class="form-group">
            <label class="col-sm-2 control-label">出生日期</label>
            <div class="col-sm-9">
                <p class="input-group">
                    <input id="personalInformation_date_id" ng-model="assessment.personalInformation.dob" placeholder="yyyy-mm-dd" style="height: 34px;" class="form-control" type="text">
                    <span class="input-group-addon"><span class="glyphicon glyphicon-calendar"></span></span>
                    <script type="text/javascript">
                        $("#personalInformation_date_id").datetimepicker({
                            language: "zh-CN",
                            format: "yyyy-mm-dd",
                            minView: 2,
                            autoclose: true,
                            todayBtn: true,
                            pickerPosition: "bottom-left"
                        });
                    </script>
                </p>
            </div>
        </div>
        <div class="form-group">
            <label class="col-sm-2 control-label">社保号码</label>
            <div class="col-sm-9">
                <input type="text" class="form-control" ng-model="assessment.personalInformation.hino">
            </div>
        </div>
        <div class="form-group">
            <label class="col-sm-2 control-label">电子邮箱</label>
            <div class="col-sm-9">
                <input type="text" placeholder="你的邮件地址@邮件域名,例如: jack@tlr.com" class="form-control" ng-model="assessment.personalInformation.email">
            </div>
        </div>
        <div class="form-group">
            <div class="col-sm-12 tlr-split-line">
            </div>
        </div>
        <div class="form-group">
            <label class="col-sm-2 control-label">近亲</label>
            <div class="col-sm-9">
                <input type="text" class="form-control" ng-model="assessment.personalInformation.nok.name">
            </div>
        </div>
        <div class="form-group">
            <label class="col-sm-2 control-label">关系</label>
            <div class="col-sm-9">
                <input type="text" class="form-control" ng-model="assessment.personalInformation.nok.relationship">
            </div>
        </div>
        <div class="form-group">
            <label class="col-sm-2 control-label">电话</label>
            <div class="col-sm-9">
                <input type="text" class="form-control" ng-model="assessment.personalInformation.nok.tel">
            </div>
        </div>
        <div class="form-group">
            <label class="col-sm-2 control-label">地址</label>
            <div class="col-sm-9">
                <input type="text" class="form-control" ng-model="assessment.personalInformation.nok.address">
            </div>
        </div>
        <div class="form-group">
            <label class="col-sm-2 control-label">电邮</label>
            <div class="col-sm-9">
                <input type="text" placeholder="你的邮件地址@邮件域名,例如: jack@tlr.com" class="form-control" ng-model="assessment.personalInformation.nok.email">
            </div>
        </div>
        <div class="form-group">
            <div class="col-sm-12 tlr-split-line">
            </div>
        </div>
        <div class="form-group">
            <label class="col-sm-2 control-label">代表律师</label>
            <div class="col-sm-9">
                <input type="text" class="form-control" ng-model="assessment.personalInformation.lpa.name">
            </div>
        </div>
        <div class="form-group">
            <label class="col-sm-2 control-label">关系</label>
            <div class="col-sm-9">
                <input type="text" class="form-control" ng-model="assessment.personalInformation.lpa.relationship">
            </div>
        </div>
        <div class="form-group">
            <label class="col-sm-2 control-label">电话</label>
            <div class="col-sm-9">
                <input type="text" class="form-control" ng-model="assessment.personalInformation.lpa.tel">
            </div>
        </div>
        <div class="form-group">
            <div class="col-sm-12 tlr-split-line">
            </div>
        </div>
        <div class="form-group">
            <div class="col-sm-12 tlr-split-line">
                <label class="col-sm-2 control-label tlr-h3">其他联系人</label>
            </div>
        </div>
        <div class="form-group">
            <label class="col-sm-2 control-label">姓名</label>
            <div class="col-sm-9">
                <input type="text" class="form-control" ng-model="assessment.personalInformation.otherContacts[0].name">
            </div>
        </div>
        <div class="form-group">
            <label class="col-sm-2 control-label">电话</label>
            <div class="col-sm-9">
                <input type="text" class="form-control" ng-model="assessment.personalInformation.otherContacts[0].tel">
            </div>
        </div>
        <div class="form-group">
            <label class="col-sm-2 control-label">关系</label>
            <div class="col-sm-9">
                <input type="text" class="form-control" ng-model="assessment.personalInformation.otherContacts[0].relationship">
            </div>
        </div>
        <div class="form-group">
            <div class="col-sm-12 tlr-split-line">
            </div>
        </div>
        <div class="form-group">
            <div class="col-sm-12 tlr-split-line">
                <label class="col-sm-2 control-label" style="padding-left: 40px; font-size: 16px;">相关专家</label>
            </div>
        </div>
        <div class="form-group">
            <label class="col-sm-2 control-label">全科医生</label>
            <div class="col-sm-9">
                <input type="text" class="form-control" ng-model="assessment.personalInformation.professionals[0].name">
            </div>
        </div>
        <div class="form-group">
            <label class="col-sm-2 control-label">电话</label>
            <div class="col-sm-9">
                <input type="text" class="form-control" ng-model="assessment.personalInformation.professionals[0].tel">
            </div>
        </div>
        <div class="form-group">
            <label class="col-sm-2 control-label">地址</label>
            <div class="col-sm-9">
                <input type="text" class="form-control" ng-model="assessment.personalInformation.professionals[0].address">
            </div>
        </div>
        <div class="form-group">
            <div class="col-sm-12 tlr-split-line">
            </div>
        </div>
        <div class="form-group">
            <label class="col-sm-2 control-label">专科医生</label>
            <div class="col-sm-9">
                <input type="text" class="form-control" ng-model="assessment.personalInformation.professionals[1].name">
            </div>
        </div>
        <div class="form-group">
            <label class="col-sm-2 control-label">电话</label>
            <div class="col-sm-9">
                <input type="text" class="form-control" ng-model="assessment.personalInformation.professionals[1].tel">
            </div>
        </div>
        <div class="form-group">
            <label class="col-sm-2 control-label">地址</label>
            <div class="col-sm-9">
                <input type="text" class="form-control" ng-model="assessment.personalInformation.professionals[1].address">
            </div>
        </div>
        <div class="form-group">
            <div class="col-sm-12 tlr-split-line">
            </div>
        </div>
        <div class="form-group">
            <label class="col-sm-2 control-label">牙医</label>
            <div class="col-sm-9">
                <input type="text" class="form-control" ng-model="assessment.personalInformation.professionals[2].name">
            </div>
        </div>
        <div class="form-group">
            <label class="col-sm-2 control-label">电话</label>
            <div class="col-sm-9">
                <input type="text" class="form-control" ng-model="assessment.personalInformation.professionals[2].tel">
            </div>
        </div>
        <div class="form-group">
            <label class="col-sm-2 control-label">地址</label>
            <div class="col-sm-9">
                <input type="text" class="form-control" ng-model="assessment.personalInformation.professionals[2].address">
            </div>
        </div>
        <div class="form-group">
            <div class="col-sm-12 tlr-split-line">
            </div>
        </div>
        <div class="form-group">
            <label class="col-sm-2 control-label">眼科医生</label>
            <div class="col-sm-9">
                <input type="text" class="form-control" ng-model="assessment.personalInformation.professionals[3].name">
            </div>
        </div>
        <div class="form-group">
            <label class="col-sm-2 control-label">电话</label>
            <div class="col-sm-9">
                <input type="text" class="form-control" ng-model="assessment.personalInformation.professionals[3].tel">
            </div>
        </div>
        <div class="form-group">
            <label class="col-sm-2 control-label">地址</label>
            <div class="col-sm-9">
                <input type="text" class="form-control" ng-model="assessment.personalInformation.professionals[3].address">
            </div>
        </div>
        <div class="form-group">
            <div class="col-sm-12 tlr-split-line">
            </div>
        </div>
        <div class="form-group">
            <label class="col-sm-2 control-label">足病医生</label>
            <div class="col-sm-9">
                <input type="text" class="form-control" ng-model="assessment.personalInformation.professionals[4].name">
            </div>
        </div>
        <div class="form-group">
            <label class="col-sm-2 control-label">电话</label>
            <div class="col-sm-9">
                <input type="text" class="form-control" ng-model="assessment.personalInformation.professionals[4].tel">
            </div>
        </div>
        <div class="form-group">
            <label class="col-sm-2 control-label">地址</label>
            <div class="col-sm-9">
                <input type="text" class="form-control" ng-model="assessment.personalInformation.professionals[4].address">
            </div>
        </div>
        <div class="form-group">
            <div class="col-sm-9">
                <input class="btn btn-default" style="float: right;" type="button" value="下一页" ng-click="nextPage(2)">
                <input class="btn btn-default" style="float: right; margin-right: 30px;" type="button" value="上一页" ng-click="prevPage(0)">
            </div>
        </div>
    </form>
</div>